What is the immediate management of eclampsia, including seizure control, severe hypertension treatment, and timing of delivery?

Management of Eclampsia

Immediate Seizure Control

Magnesium sulfate is the first-line anticonvulsant for eclampsia and must be administered immediately to control seizures and prevent recurrence. 1, 2, 3

• Loading dose: 4–5 g IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% normal saline) 1
• Maintenance infusion: 1–2 g/hour continuous IV 1
• Duration: Continue for 24 hours postpartum 4
• Monitor for magnesium toxicity by assessing deep-tendon reflexes, respiratory rate (should be >12/min), and urine output (should be ≥30 mL/hour) 4
• Critical FDA warning: Magnesium sulfate should be reserved for immediate control of life-threatening convulsions; continuous administration beyond 5–7 days can cause fetal hypocalcemia, skeletal demineralization, osteopenia, and neonatal fractures 5

Alternative Anticonvulsants (If Magnesium Sulfate Unavailable)

• If magnesium sulfate is contraindicated or unavailable, benzodiazepines may be used as second-line agents, though they are significantly less effective 3

Acute Hypertension Management

Treat severe hypertension (≥160/110 mmHg persisting >15 minutes) immediately to prevent maternal cerebral hemorrhage and stroke. 1, 2

First-Line IV Antihypertensive Options

• IV labetalol: 20 mg initial bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes (maximum cumulative dose 220 mg) 6, 1, 2
• IV hydralazine: 5–10 mg bolus every 20 minutes as needed 6, 1, 2
• IV nicardipine infusion: Start at 5 mg/hour, increase by 2.5 mg/hour every 5–15 minutes to maximum 15 mg/hour 6, 4

Oral Alternative (If IV Access Delayed)

• Immediate-release nifedipine: 10–20 mg orally, repeat every 20–30 minutes if needed 1, 4, 2
• CRITICAL WARNING: Avoid sublingual nifedipine, especially when combined with magnesium sulfate, due to risk of precipitous hypotension, stroke, myocardial infarction, and fetal distress 6, 4

Blood Pressure Targets

• Acute phase: Systolic <160 mmHg and diastolic <110 mmHg 6, 1, 7
• Maintenance: Systolic 110–140 mmHg and diastolic 85 mmHg 6, 1, 4

Airway and Supportive Care During Seizure

Position the patient in left lateral decubitus to prevent aspiration and optimize uteroplacental perfusion. 8

• Maintain airway patency and provide supplemental oxygen 8, 9
• Protect the patient from injury during convulsions 2, 9
• Avoid placing objects in the mouth during active seizure 9
• Prepare for potential difficult intubation if general anesthesia becomes necessary 8

Fluid Management

Strictly limit total IV fluid intake to 60–80 mL/hour to prevent iatrogenic pulmonary edema. 6, 1, 4

• Aim for euvolemia; avoid aggressive "dry" restriction as this increases acute kidney injury risk 1, 4
• Do NOT use diuretics routinely—they further reduce plasma volume, which is already contracted in eclampsia 6, 4
• If pulmonary edema develops, initiate IV nitroglycerin at 5 mcg/min, increasing by 5 mcg/min every 3–5 minutes to maximum 100 mcg/min 1, 4

Laboratory Assessment

Obtain immediate laboratory workup to assess for complications and guide management: 1

• Complete blood count with focus on hemoglobin and platelet count (thrombocytopenia <100,000/μL indicates severe disease) 1
• Comprehensive metabolic panel: liver transaminases (AST/ALT), creatinine, uric acid 1
• Coagulation studies to screen for disseminated intravascular coagulation 9
• LDH and haptoglobin to evaluate for hemolysis (HELLP syndrome) 4
• Spot urine protein/creatinine ratio 1

Timing and Mode of Delivery

Delivery is the definitive treatment for eclampsia and should occur after maternal stabilization, regardless of gestational age. 6, 1, 8

Delivery Approach

• Vaginal delivery is preferred unless obstetric indications mandate cesarean section 6, 8, 2
• Attempting vaginal delivery is appropriate only if rapid completion is possible with stable maternal and fetal status 8
• Immediate cesarean section is most often recommended for eclampsia 8
• Maintain left lateral positioning during cesarean section 8

Anesthesia Considerations

• Regional anesthesia (epidural or spinal) is preferred for conscious, seizure-free patients without coagulopathy or HELLP syndrome 8, 10, 2
• Regional anesthesia reduces risk of aspiration and failed intubation 8, 10
• General anesthesia should be used for sudden, unexpected interventions or when the patient arrives seizing without laboratory results; requires experienced anesthesiology team prepared for difficult intubation 8, 2

Corticosteroids for Fetal Lung Maturity

• If gestational age <34 weeks and delivery can be safely delayed 48 hours, administer betamethasone 12 mg IM every 24 hours × 2 doses 1, 4

Intrapartum Blood Pressure Control

• Continue antihypertensive therapy throughout labor and delivery to maintain systolic <160 mmHg and diastolic <110 mmHg 6, 4

Postpartum Management

Eclampsia can occur for the first time postpartum; approximately 44% of eclamptic seizures occur after delivery, with 50% presenting within the first 48 hours. 7, 3, 9

• Continue magnesium sulfate infusion for 24 hours postpartum 4
• Monitor blood pressure every 4–6 hours while awake for at least 3 days postpartum 1, 7, 4
• Continue or restart antihypertensive medications; taper slowly only after days 3–6 postpartum unless blood pressure falls below 110/70 mmHg 1, 7, 4
• Avoid NSAIDs for postpartum analgesia, especially if renal impairment, placental abruption, or acute kidney injury is present; use alternative analgesics 1, 7, 4
• Repeat hemoglobin, platelets, creatinine, and liver transaminases daily until stable 7

Patient Education

• Educate women about warning signs: severe headache, visual changes, epigastric or right upper quadrant pain, shortness of breath 7, 9
• Instruct patients to contact healthcare professionals immediately if warning signs develop during the first 4 weeks postpartum 7

Follow-Up and Long-Term Counseling

• Schedule comprehensive review at 3 months postpartum to confirm normalization of blood pressure, urinalysis, and laboratory parameters 1, 7, 4
• Refer women with persistent hypertension or proteinuria at 6 weeks to a specialist 6, 7
• Counsel about recurrence risk: Approximately 1–2% risk of eclampsia and 22–35% risk of preeclampsia in subsequent pregnancies 1, 3
• Counsel about long-term cardiovascular risk: Women with eclampsia have markedly increased lifetime risk of cardiovascular disease, stroke, type 2 diabetes, venous thromboembolism, and chronic kidney disease 1, 7, 4
• Recommend low-dose aspirin (75–162 mg daily) starting before 16 weeks gestation in future pregnancies 1, 4

Critical Pitfalls to Avoid

• Do NOT delay magnesium sulfate administration—it is the only proven anticonvulsant that reduces eclamptic seizures by more than 50% 10, 3
• Do NOT use sublingual nifedipine, particularly with concurrent magnesium sulfate, due to risk of severe hypotension and myocardial depression 6, 4
• Do NOT combine IV magnesium with calcium channel blockers due to synergistic myocardial depression 4
• Do NOT use ACE inhibitors during second and third trimesters—they are absolutely contraindicated due to fetal renal dysgenesis 4
• Do NOT delay delivery once maternal stabilization is achieved; delivery is the definitive treatment regardless of gestational age 6, 1, 8
• Do NOT use sodium nitroprusside for >4 hours due to risk of fetal cyanide and thiocyanate toxicity 6
• Do NOT underestimate postpartum risk—up to 44% of eclamptic seizures occur after delivery, and vigilance must continue for at least 4 weeks 7, 3, 9